university of ottawa/ cihr the ottawa model of research use ian d graham, phd canadian institutes of...
TRANSCRIPT
University of Ottawa/ CIHR
The Ottawa Model of Research Use
Ian D Graham, PhD
Canadian Institutes of Health ResearchSchool of Nursing, UOttawa
Sept. 24, 2007
University of Ottawa/ CIHR
University of Ottawa/ CIHR
What do we know about research use?
• Uptake of research influenced by:– Perceptions of the innovation- (ie the evidence,
CPGs)– The potential adopter– The practice setting or social context
University of Ottawa/ CIHR
Factors influencing uptake of innovations:
The Innovation
•Development process
•Attributes of the innovation
University of Ottawa/ CIHR
Credible developersall relevant stakeholders
interdisciplinary
Objective & rigorous method
Careful documentationexplicit & transparent process
Local involvement
Development Process
University of Ottawa/ CIHR
• Relative advantage (useful)• Low complexity (ease of use or do)• Compatible
•(fits with current practice, norms/values)•(does not demand change in existing practice)
• Trialability (easy to try)• Clear (not vague or non-specific)• Evidence-based• Re-invention
(Rogers 1995) (Grilli and Lomas, 1994) (Grol et al 1998) (Foy et al 2003)
Characteristics of the Innovation
University of Ottawa/ CIHR
Factors influencing uptake of innovations:
Potential Adopters• awareness
• attitudes
• knowledge/skill
• concerns
• current practice/habit
University of Ottawa/ CIHR
Factors influencing uptake of innovations:
Practice Environment- Structure Factors– Decision-making – Policies, rules, laws– Available technology: equipment, testing– Physical layout– Work pressure (info overload, competing demands, no
time, chaotic environment)– Human resources
University of Ottawa/ CIHR
• Culture & belief systems
– Norms, institutionalized habits
• Leadership
• Politics & personalities
• Peer influence
Practice Environment: Culture/social Factors
University of Ottawa/ CIHR
Practice Environment: Other Factors
• Patients/Consumers– Case mix, behavior, attitudes, preferences & demands
• Economic Considerations– Resources, remuneration, funding systems
• Medical/Legal Issues
• Other Organizational/System Factors
University of Ottawa/ CIHR
What do we know about the effectiveness of implementation interventions?
• Cochrane’s EPOC (Effective Practice and Organization of Care) Group
• Systematic reviews of:– Professional interventions (e.g. continuing medical education, audit
and feedback)
– Organizational interventions (e.g. the expanded role of pharmacists)
– Financial interventions (e.g. professional incentives)
– Regulatory interventions
University of Ottawa/ CIHR
Effectiveness of Knowledge Translation/implementation Interventions (Bero et al., 1998, Grimshaw et al., 2001,
Grimshaw, 2004)
Little or no effect• Educational materials*• Didactic educational
meetings
Sometimes effective• Audit and feedback• Local opinion leaders• Local consensus processes• Patient mediated
interventions
University of Ottawa/ CIHR
Generally Effective
• Educational outreach visits• Reminders• Interactive educational meetings• Multifaceted interventions including two or
more of:
– Audit and feedback– Reminders– Local consensus processes– Social marketing
University of Ottawa/ CIHR
Summary of Reviews on KT/Implementation Interventions
• No magic bullets- most interventions effective under some circumstances, none effective under all circumstances
• Multiple ongoing interventions are usually necessary
• Evidence is sparse for many interventions
University of Ottawa/ CIHR
How Can We Facilitate Knowledge to Practice?
• Need a Conceptual Framework to Guide Implementation
• Planned action vs classic theories of change
University of Ottawa/ CIHR
Assess + Monitor + Evaluate
Practice Environment
Potential Adopters
Innovation
Interventions
Adoption
Outcomes
Ottawa Model of Research Use
University of Ottawa/ CIHR
Getting Started• Who is wanting to bring about the change in
practice? Where are they located in the social system?
• What is their jurisdiction & scope of activities they can perform?
• What are their strategic alliances?
• What resources are available?
• Who is going to be the change agent(s)/facilitator(s)?
University of Ottawa/ CIHR
Assess + Monitor + Evaluatebarriers & supports interventions outcomes & degree of use
Practice Environment
Potential Adopters
Innovation
(CPG, tools)
Interventions Adoption Outcomes
Ottawa Model of Research Use
University of Ottawa/ CIHR
Assess + Monitor + Evaluatebarriers & supports interventions outcomes & degree of use
Practice Environment
Potential Adopters
Innovation
Implementation
Interventions
• barrier
management • transfer• follow-up
Adoption Outcomes
Ottawa Model of Research Use
University of Ottawa/ CIHR
Assess + Monitor + Evaluatebarriers & supports interventions outcomes & degree of use
Practice Environment
• structural• culture/social• patients• economic
Potential Adopters
• awareness• attitudes• knowledge/skill• concerns• current practice
Innovation (guideline)
• development process
• innovation attributes
Interventions• barrier
management • transfer• follow-up
Adoption• intention• use• sustained
use
Outcomes• patient• practitioner• system
Ottawa Model of Research Use
University of Ottawa/ CIHR
Assess + Monitor + Evaluatebarriers & supports interventions outcomes & degree of use
Practice Environment
• structural• culture/social• patients• economic
Potential Adopters
• awareness• attitudes• knowledge/skill• concerns• current practice
Innovation• development
process• innovation
attributes
Interventions• barrier
management • transfer• follow-up
Adoption• intention• use• sustained
use
Outcomes• patient• practitioner• system
Ottawa Model of Research Use
University of Ottawa/ CIHR
Additional References• Logan J, Graham, ID. Toward a Comprehensive
Interdisciplinary Model of Health Care Research Use. Science Communication 1998;20(2):227-246.
• Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can J Nurs Res. 2004 Jun;36(2):89-103.
• RNAO Implementation of Practice Guidelines Toolkit http://www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf
• Grimshaw et al 2004. Systematic review of the effectiveness and efficiency of guideline dissemination and implementation strategies. Htpp://www.ncchta.org/project.asp?PjtId=994
University of Ottawa/ CIHR
Adoption and sustainability of decision
support for patients facing health decisions:
An implementation case study with
embedded RCT
Dawn Stacey RN PhD
Assistant Professor, University of Ottawa
Funding: Canadian Institutes of Health Research
September 2007
University of Ottawa/ CIHR
Outline
• Background
• Purpose & Objectives
• Theoretical Framework
• Methods
• Results
• Implications for Research, Education and Practice
University of Ottawa/ CIHR
Public’s view on who should make risk-related health decisions
5%
6%
6%
3%
10%
4%
26%
29%
36%
33%
38%
36%
69%
63%
57%
64%
51%
60%
0% 20% 40% 60% 80% 100%
USA
Canada
UK
Germany
S. Africa
Japan
MD makes decision MD gives options & his/her opinion
MD gives options & lets pt decide Not Sure
(Magee, WHO, 2003)
University of Ottawa/ CIHR
University of Ottawa/ CIHR
Problem: Decisional ConflictProblem: Decisional Conflict
uncertainty about which course of action to take
North American Nursing Diagnosis North American Nursing Diagnosis Association, 2002Association, 2002
yesyes
nono
University of Ottawa/ CIHR
‘‘InnateInnate’ ’ contributing factorscontributing factors
2 or more options
Outcomes: risky/uncertain, permanent, serious
Value tradeoffs: benefits versus harms
Anticipated regret: ‘missed’ benefits of option not chosen
University of Ottawa/ CIHR
ConsequencesConsequences: : unresolved decisional unresolved decisional conflict & related factorsconflict & related factors
• 59 times more likely to change mind• 23 times more likely to delay decision• 5 times more likely to have regret• 3 times more likely to fail knowledge test• 19% more likely to blame practitioner for bad
outcomes
(Sun, Q. [MSc thesis]. University of Ottawa, 2005; Gattelari & Ward J Med Screen 2004;11:165-169)
University of Ottawa/ CIHR
Compared to standard care, Compared to standard care, patient decision aids…patient decision aids…
Improve decision quality 15% higher knowledge scores 70% more realistic
expectations (probabilities) better match between values &
choices
Reduce decisional conflict (9 points)
Help undecided to decide (50%)
Patients 40% less passive in decisions
Reduce over-use -25% surgery; -20% PSA; -29%
HRT
Potential to reduce under-use O’Connor et al., Medical Decision Making, 2007
University of Ottawa/ CIHR
ValueValueof coachingof coaching[hysterectomy]
(Kennedy et al. JAMA 2002; 288: 2701-2708)
University of Ottawa/ CIHR
Framework for Decision Coach-Mediated Shared Framework for Decision Coach-Mediated Shared
Decision MakingDecision Making Primary Clinician Role to diagnose patient problem; discuss options; screen for decisional conflict; refer for decision support
Goal: Informed decision making based on
patients’ priorities & values
Patient RoleCommunicate informed values & priorities shaped by their social circumstances
Decision Coach Role (Ottawa Decision Support Framework)
1. Assessing decisional needs
2. Providing decision support tailored to needs
3. Monitoring & facilitating progress in resolving needs and decision quality
4. Screen for implementation needs
(Stacey, Murray et al., Worldviews on Evidence-based Nursing in press)
University of Ottawa/ CIHR
Client Centred CareClient Centred Care
RNAO Nurse Best Practice Guideline: Client RNAO Nurse Best Practice Guideline: Client Centred Care Centred Care (2006)(2006)
“Nurses have a central role in providing clinical expertise to facilitate clients’ decision making…to reach decisions that are well-informed and best for them” (p.3)• Involve clients in decision making• Provide structured decision support using patient decision aids and decision coaching
“Providing care that is respectful of and responsive to individual patient preferences, needs and values and
ensuring that patient values guide all clinical decisions” (p.6, Institute of Medicine, 2001)
University of Ottawa/ CIHR
Purpose of research
A case study with an embedded randomized controlled trial (RCT), guided by the Ottawa Model of Research Use
1. To explore baseline barriers and facilitators re decision support/coaching by call centre nurses
2. To design and evaluate a multifaceted intervention to improve the quality of nurses’ decision support
3. To describe the uptake and sustainability of decision support by call centre nurses
Ethics approval by University of Ottawa, Research Ethics Board
University of Ottawa/ CIHR
BCNurseLine call centreServes population of 4.2 million since 2001
• Goal – To help BC residents manage personal health issues and make
‘sound’ health decisions
• Healthwise® Knowledgebase resources– Public access to a handbook and internet-based health information
including 95+ patient decision aids
• Concurrent initiatives Dec 03 to June 04
– Major reorganization of nurse supervisors positions
– Imminent contract renewal for call centre services
– High absenteeism increased call pressure
University of Ottawa/ CIHR
Decision Point Top Hits at BCNurseLine
• Breast or bottle feeding
• Birth control method
• Treatment for miscarriage
• Removing wisdom teeth
• Amniocentesis
• Antibiotics for acute bronchitis
(884 hits total for 2003)
University of Ottawa/ CIHR
Assess + Monitor + Evaluatebarriers & facilitators interventions outcomes & degree of use
Practice Environment
BCNurseLine• organization’s policies,
mandate• callers
Potential Adopters:
Nurses• awareness• attitudes• knowledge/skill• confidence• current practice
Innovation
Decision supportMultifaceted intervention
• online autotutorial
• decision support /coaching protocol
• skill workshop
• performance feedback
Adoption• intention• use
Outcomes• patient• practitioner• system
Ottawa Model of Research Use
(Logan J & Graham ID, 1998; Graham ID & Logan J 2004)
1. Baseline assessment
2. RCT of intervention
3. Uptake & sustainability
University of Ottawa/ CIHR
Case study method (Dec ‘03 to June ‘04)
Analysis• Conceptual content analysis of qualitative data • Descriptive analysis of surveys; t-tests and ANCOVA for trial data• Triangulation of results across data sources
(Creswell JW, 1998; Sidani S & Braden CJ, 1998; Yin R, 2003)
Data SourcesDec- Feb- Apr
Jan (n) Mar (n) June (n)
Key informant interviews 4 4
Focus groups with nurses 7 8
Survey: barriers/facilitators 57 of 108
Quality audit simulated patient calls 38 of 39 39 of 39
RCT – intervention evaluation 39 of 41
Survey: uptake, sustainability 25 of 31
Organizational documents <-------Continuous------->
University of Ottawa/ CIHR
RCT methods
21 Intervention(knowledge test;
acceptability surveys)
41 call centre RNs
R
20 Control (knowledge test)
Stratified by FTE status
41 simulated calls*
19+ simulated calls 20 simulated calls
(* Missed taping 1 call; + 2 dropped at the beginning of the intervention)
December 2003
February 2004
April 2004
12 interventionMay 2004
University of Ottawa/ CIHR
Characteristics of participants
%
University of Ottawa/ CIHR
Baseline facilitators for nurses providing decision support/coaching
• Innovation: – Access to >95 patient decision aids
• Potential adopters: Nurses– Positive attitudes
– Already refer to patient decision aids
– Recognize callers having difficulty with decisions
• Practice Environment: Call centre infrastructure– supervisors/educators– classification of calls
(Stacey, Graham, O’Connor, Pomey. Worldviews Evidence-based Nursing, 2005: 2: 184-195)
University of Ottawa/ CIHR
Key Elements of Quality Decision Support Provided by Nurses to Simulated Callers (N=38)
University of Ottawa/ CIHR
Baseline barriers to nurses providing decision support
• Innovation:
– Inefficiency to find/use decision aids in database
– No structured process to guide calls
• Potential adopters: Nurses
– Lack knowledge, skill, confidence
• Practice Environment: Call centre infrastructure– Unclear program mandate
– Organizational pressure to minimize call length
– Low public awareness of call centre services
University of Ottawa/ CIHR
Multifaceted intervention to address baseline barriers
BarriersOnline auto-
tutorial
Skill-building workshop
Performance feedback
(simulated call)
Decision support protocol
Locating & using patient decision aids
Lack of structured process to guide callers
X
Nurses’ knowledge X X
Nurses’ skills X
Unclear program mandate
Call length pressure (12.5 minute target)
Low public awareness(Grimshaw J, et al., 2001 & 2004; Thomas L, et al., 1999)
University of Ottawa/ CIHR
A process for coaching clients making
decisions with 2 or more options
Available at www.ohri.ca/decisionaid
Decision support protocol
Based on: Ottawa Decision Support Framework
University of Ottawa/ CIHR(Stacey et al., 2006, J Telemed & Telecare)
Time in Minutes
RCT to Enhance RCT to Enhance Nurse Decision Nurse Decision
Support CoachingSupport Coaching
University of Ottawa/ CIHR
Health professionals’ decision support Health professionals’ decision support knowledgeknowledge
%
(Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)
University of Ottawa/ CIHR
Coaches’ decision support skills improveCoaches’ decision support skills improve (simulated
calls)
Mean quality scores
p < 0.001
(Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)
University of Ottawa/ CIHR
Adoption of decision support
• 25 of 31 trained nurses completed the survey
• Of 25 nurses,
– 23 plan to use decision support protocol next 3 months
– 21 felt comfortable using it
– 11 already used it with callers
– 14 did not receive an appropriate call
• “It was just plunge in, see what you do the first time…And I may not have been right on all of them but I could see where I missed. The next one I thought was better.”
(Stacey et al., Implementation Science, 2006)
University of Ottawa/ CIHR
Use with real callers: comments
• Recognized the need for decision support“It was a medication call and she had quite a few questions. But underlying it all, was her concern about how to select birth control.”
• Felt better prepared “I’m more likely to ask questions about the decision … instead of just making assumptions, which is a lot of what I did earlier.”
• Felt positive about their practice“I used to feel quite nervous that …I felt like I should know the answer. So this has given me a lot of power that you can help them, that you don’t have to sort it out for them.”
University of Ottawa/ CIHR
Factors influencing sustainability of decision support by nurses
• Innovation: Decision support tools – usable via telephone, integrated in database, auto-charting
• Potential Adopters: nurses – Continuing education for ongoing skills development
• Practice environment: call centre– extended for all nurses
– monthly call audit of decision support calls
– Clear program direction/mandate
– Call length guidelines tailored to decision support calls
– Market decision support services to public
University of Ottawa/ CIHR
Limitations of research
• Response biases– low response rate to survey (53%)
• Hawthorne effect – not blinded to simulated calls
• Generalizability of findings– other nurses (within call centre and other centres)
University of Ottawa/ CIHR
Research, education, & policy implications
• Further research to study– Effect on real patient calls
– Impact on nurses’ perceptions of their practice
• Need interventions to address unresolved practice environment barriers
– Organizational mandate, call length guidelines, marketing of services
– Telephone-friendly decision support resources
• Re-assess competencies in health professionals’ education programs
University of Ottawa/ CIHR
Key MessagesKey Messages• Effective interventions can address potential adopters’
barriers to implementing decision support in their practice
– By increasing awareness, knowledge, skills
• Assessment of barriers and facilitators sensitizes potential adopters to innovation
• Interventions to manage barriers in practice environment are more challenging
• Environmental barriers are likely to interfere with sustainable practice changes
University of Ottawa/ CIHR
Acknowledgements
Appreciation is expressed to
– Nurses who shared their experiences
– Annette O’Connor, Ian Graham, Marie-Pascale Pomey for their expert advice and guidance throughout the study
Funding
– Ontario MOH and Canadian Institutes of Health Research (CIHR) Doctoral Studies Award
– CIHR Group Grant on Decision Support Tools for Clinicians and Patients
– In-kind support from the BC Ministry of Health Services and TCM TeleCare
University of Ottawa/ CIHR
A mind once stretched by a new idea never
regains
its original dimensionOliver Wendell Holmes Jr.
US jurist (1841 - 1935)
University of Ottawa/ CIHRwww.ohri.ca/decisionaidwww.ohri.ca/decisionaid